YE Y 01\ T AGENCY OF HUMAN SERVICES

DEPARTMENT OF DISAIIILITIES, AGING AND INDEPENDENT LIVING

Division of Licensing and Protection 103 South Main Street, Ladd Hall

Waterbury VT 05671-2306 http://www.daiLvermont.gov

Voice/TTY (802) 871-3317 To Report Adult Abuse: (800) 564-1612

Fax (802) 871-3318

April 4, 2014

Timothy Ford, Administrator Springfield Hospital Po Box 2003 Springfield, VT 05156

Dear . Ford:

The Division of Licensing and Protection completed a survey at your facility on February 4, 2014. The purpose of the survey was to determine if your facility met the conditions of participation for Critical Access Hospitals found in 42 CFR Part 485.

Following the survey, your facility submitted a Plan of Corrections (POC) which was found to be acceptable on April 4, 2014.

Sincerely,

Frances L. Keeler, RN, MSN, DBA Assistant Division Director Director State Survey Agency

FK:j1

Enclosure

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An olislit aint.' e ationVaStorichStod ob:Z13/14 4 214114,5y the Division of Licensing and Pitotection..Assrestillat the Invealgation of isonipitiiiitiftlirOr be Condition of Paititipationi Staffing and Staff Was Opt met and addlthlfitai fulator9 Violations WOO not ink 485608(a) COMPLIANCE WITH FEDERAL LANS SASSALA110618

The CAR is in compiiancewith applicable Federal laws and regulations related to the health and safety of patient

TffiS STANDARD is htit tat asHeVideeced by;, .REIAliti on Wail ethillOW and Staff inteilitek the

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. Pg rocoittrewow; Pfleittli with a diagnosis of a0*Perife0IIIS disorder ar,I4 PT50i Was eCile gel to the Windham OeiTteti PPS Exclude/501s finct Fart Psychiatric Unit-of Springfield li ' ' = i on 17}1 W13 involuntary adinisSort.. Pifer to. admission Patientel was involved in a assaultive incident on 4116113 at an outpatient Mental health agencycesulting in police intervention and Stibseluent in/lir to Staff at the Agetielt. The eget* had beeil Otoviding ftIebtal boaab

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Documentation: Staff will be re-educated to accurately document patient assessments to identify at risk behaviors that accurately indicate a requirement for increased staffing; implementation of therapeutic alternatives; consideration of seclusion or restraint to ensure patient safety. A Behavior Flow Sheet will be developed that identifies and provides documentation for: at risk behaviors- interventions implemented; outcome of treatment. Monitoring: Behavior flow sheets will be reviewed to assess completion of appropriate assessments; Implementation of appropriate interventions; and treatment outcomes. Goal: All patients are treated with dignity and respect. Follow up Any failure to comply will result in review of situation and re-education with staff and identification of further improvement efforts. Therapeutic Alternatives

- At Windham Center As patient assessment warrants and is supported by documentation, therapeutic alternatives will be considered. These measures include. Physiologic measures: Comfort measures, positioning measures, and relaxation techniques. Activity diversion measures: Distraction, music, exercise Psychosocial measures: Companionship or patient sitter, reality orientation, active listening, verbal interventions, discussion of patient/family preferences or insights related to less restrictive measures fickr c1ioe1 „Gee F.

LALICMATORY MitECTOR'S OR PROVIDERiSUPPLIER REPRESENTAT 'EV TURE TITLE DO) DATE L.) 3

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My deflOaricY statement ending **Ilan* fetish tl eliiotes a daficie*PY *deb iholl3s!Oithile may be excused won:R*1'40dg DO/ Oa is 4e-termer that other safeguards. provide attificiptit prolection to itippatients. Caiie tostrocfitiriol Fieceptior noising home*, siniinaingsstiiteil owe ere dielossea eti.days following the date of_sereey whether or net a plan of correction is provkled. For nursing 60/11e*thestedye findings and plans of correction are iliodosable 14 tletielcithuMou the-elate These documents ere &Meet:wadable to the &doily: lidofioioddies me teed, an approved plan oftotrectionietequieltelo continued. CitOtitein FliftiC10111211.

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-C ISI Monitoring 100% record review will occur to assure therapeutic alternatives are provided for patients exhibiting documented at risk behaviors. Goal: All patients are treated with dignity and respect. Follow up Any failure to comply will result in review of situation and re-education with staff and identification of further improvement efforts. Windham Center Staffing: Additional staffing will be requested for patients exhibiting at risk behaviors that are documented and include threats of aggression, violence and self-harm. Additional staffing ratio may require 1:1 / 2:1 staffing. Security staff may be requested as situation warrants and is documented. In all instances patients will be provide care with dignity and respect. Current per diem staffing pool has been increased by 5 staff members that have been trained and educated in the management of Windham Health Center population. Monitoring 100% daily review of Windham Center inpatient census to determine if staffing levels meet patient acuity requirements. Review of all patients where a change in status occurs for appropriate implementation of therapeutic alternatives and for the employment of additional staffing. Follow up Failure to comply will result in review of situation and re-education with staff and identification of further improvement efforts. Seelusion/Restraint: When all other less restrictive treatments fail, seclusion/restraint may be considered as a viable alternative to protect patient safety. All criteria of the Seclusion and Restraint Policy must be met prior to placing anypatient into seclusion or restraint. Patients will be frequently reassessed for release from seclusion or restraint Staff will be re-educated through review of the Restraint and Seclusion Policy.

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Monitoring 100% record review of all patients exhibiting at risk behaviors: to identify where all other alternative interventions fail that seclusion is considered and appropriately implemented; and that if employed, patient is frequently assessed and seclusion is removed when patient is no longer considered at risk. Documentation of completed of seclusion/restraint education. Follow up Any failure to comply will result in review of situation and re-education with staff and identification of further improvement efforts.

Police involvement with patients of the Windham Center A policy will be developed to identify appropriate police involvement for patients of the Windham Center. Staff will receive education to this policy. Monitoring The Nurse Manager and the Medical Director of the Windham Center will review any incidence of police presence at the Windham Center. Events and patient rights and digmity will be reported and that a review these events will occur. Follow up Failure to comply with the policy will result in case review and re-education with staff. Emergency Involuntary Medication Administration The cutteut Windham Center policy for managing emergency involuntary medication management will be revised to include: The Windham Center will provide emergency medication administration based upon documented assessment of the patient' and their need for emergency medication. Staffing requirement will be met prior to administration of emergency involuntary medication administration.

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C 151

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Monitoring 100% review of patient receiving emergency involuntary medication will occur. These reviews will be documented. Follow up Feedback will be provided to the staff regarding policy compliance and areas of needed i

Windham Center patient transfers to the Emergency Department The policy for "Medical and Acute Medical Emergencies" will be reviewed and revised. The policy will then be reviewed with all Windham center staff to provide guidelines for transfer of Windham Center patients to the Emergency Department. Monitoring The Nurse Manager and Medical Director of the Windham Center will review all cases of patients transferred to the Emergency Department using the guidelines from the policy and document their findings. Feedback will be given to staff based on those findings. Follow up Failure to adhere to policy will result in immediatere-education of staff and case review.

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Current per die staffing pool has been increased by 5 staff members that have been trained and educated in the management of Windham Health Center population. Monitoring 100% daily review of Windham Center inpatient census to determine if staffing levels meet patient acuity requirements. Review of all patients where a change in status occurs for appropriate implementation of therapeutic alternatives and for the employment of additional staffing. Follow up Failure to comply will result in review of situation and re-education with staff and identification of further improvement efforts.

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From:HetJets Bradley Office 802 885 7389

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G. 254 OentiniiO4:1PlAt+1 Page 5 4pillIV4W#y staff let lottOolvo•tgotiovtortokor4 ether patients. ThScehlY OuraoIrogre0 I,00 *Titrott 00ttglitt-Poti9ot being trOS0i tetg SPCAN0 1-10SPIO Emergency PopcortroorttiHRM for elotoottoovto..1Yrittart by Ito aeCtieteh5&1.. Num tkisi) Ot It10.0 PM The PPS sletalle-.510 ... hatlentee hobs otooNortionkolgitoScli alld tearful, and adrnittkig to hearcitg voices. the nurse;furtherstates thatthe patientinitkilly spit outepsychoMsiai medioaffonto help sedate Beiniher] and was placed on IS minute ObSerintlieliS tat earia*, Thatiaouittentation on the 15 nanittethServattan form -detail* the patent ford 9:15 PM until trasisferte ttte:E11 as folloWS: „,,,With eta% whispering, resting, lyMa On flat*,

egita:Mtf and crying.„....n, There Is rio doeureohlofto h le the nurse's note regarding the patient beingrittent, threatening, Or trtimattpteable_ There is riti deccrientatibri in the Medical record that the Patient reettirel altii tthergehey ihtettfertheheortat tbtilOot irsaster tolhO Springfield Hospital, ED. Thera is a lack if 4040thentetion ih the Metitsel Therd•tO include both PhYSi9100 notes at nursing hates that Patihnt12-tne411*)s second evaitri5on for POeeitite MOW reasons; in Segverovi in the I:Mt/01Lihb HitOttOOOk MOPItrOol Oen.* 'asiakolitert-

For** *Ow of the :Magical rhcordi thehl9teh' azat the POI received a verhaltirderst15:15 PM Prt051251019 transfer Patient W. to the SOrthgrild EU. The physician order is accompanied by a physician discharge summa dictated on 3/512013 that states the nursing sta judged the patient to he toosoute to remairton The unit, and was transferred to thd emergency department for reeviluatiOn, setiatieri if necessary, and disposition to a more aPPPOOdate facility.

c 2 — iitit" if o. D cumentation:

Staff will be re-educated to accurately document patient assessments to identify at risk behaviors that accurately indicate a requirement for increased staffing, implementation of therapeutic alternatives; consideration of seclusion or restraint to ensure patient safety. A Behavior Flow Sheet will be developed that identifies and provides documentation far: at risk behavior interventions implemented; outcome of treatment Monitoring: Behavior flow sheets will be reviewed to assess completion of appropriate assessments; Implementation of appropriate interventions; and treatment outcomes. Goal: All patients are treated with dignity and respect. Follow up Any failure to comply will result in review of re situation and-re-education with staff and identification of further improvement efforts

FORM letilIS2513/(o243) PreViots'Vetalons ObieleLA Even D: 1306

!f cooli00104 tO)esihstis a of is

From:NetJets Bradley Office 802 885 7389

DEPARTMENT OF HEALTH AEG HUMAN SERVICES GE E R I

04/02/2014 06:47 11431 P. 009/017 PRINTED: OrMt2014

FORM AWROverl

,STATEMBNTPF CEFICIENGIEE Atm PLAN OF:DORReoTion

. 1X13 RROVIDER/SUPPLIERYOUA

iciemindimoneOmesa:

411306

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11.. wine

(Xg),MULTIPLEIVISTROOTION ' (XS) DATE,SiIRvEY

COMPLETED

0210=014- ' RASPEP*0910Entt %SIM

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StRezreasgEst Om -tom 21E cObe realaoXidoi SPRINGFIRLD;vr owe

otkb ID ril*-PI IV

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nettribees PLAN OF dONNECTI6N (EACH-ORRECTIVEACTI-ON SHOULD K

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D'26s3 Ooraindenc0111. RA906

2: Per record review, of $chizoaffestive disorder admitted to the Windham I:Sttt-Part Psychiatric Hospital on 1l1t-0143 Nor to admission Patient assaulfive incident mental health agency intervenfienand subsequent agency The agency health serviCeekase peeledif& Patientitl-

Lfrationt#1 with a diagnosis and PTSD was

center! PPS Excluded Oraof Springfield

as an involuntary admission, #1 was involvedin e

1:3/611-3 at an outpatient resulting in police

injuryto Staff at the had been plawding mental rrianagement&er a 10 year wahold iiitident Ltiiitto the Patientlid was brought a

where The patient hospitalizetion..At

On 1216T13 Psdient#1 derhjAiarlt With

WS Emergency Departenerit

was Weelpilaritimith with Si and was

the-eolinlY sheriff's

am Center MurAe PreWidedaad

ProoesMa Patentii or

Upon arrival on the Patient #1 was cooperative, and interacted with staff On

expressed concerns about soine,textial Urge& and difficulty cohttathb0 Therapy PrOvided Patent

Patent #1' utilized was provided by

of 12/11/13 and Patient

takieg plot:Atm IXsytilotrOptiTtectieatiOnt

C 253`

assault en :12/0/13, local emergency depar*ment was screened for Involuntary the time of thG itteidefit Cenftritied s/he hetniteeeh

days Pet review of tioduitiefltStidni Patient-In itie.didatiort,00. 46011,0AtiVe prOviO04 WW1* by cle$101eht

_ . Aller-re‘dowt, 1D$ ...MtP0111).01:0t of trOrTSIGT! following MO fetenallifflal1a Wlndham to.n.teraccepted Invoientary-aarnission. evening of 12110/1, accepted medication 12111143, Patient.*1 hii/her ability tatentrel informed staff s/he had behaviors. Recreational #1 art supplies which effectively. Further deesoalation staff during the afternoon

FORM GMS-2E67M-9g) PIL:MousVer,aions -Obsolete Event 11-419TRil FatiliVID: -CM& If continuttiO4-shegt Patle 7 6115

From:NetJets Bradley Office

802 885 7389

04/02/2014 06:47 9431 P.010/017

DEPARTMENT OF HEALTH AND 1-4:VNIAN SERVICES CENTERSFO

Mit! ‘.11VP:. 02/14/2014 FOPNIAPPRovED

• STATEMENT ADF copENcies AND PLAN OFtetimeetaiti

vx,o- maymew000RmEnmiv4 IDEifFIMPATION NUMBER:

411300.

voiA mULTIPte K AUF-004

B. Y19A4

0 ottoc* . URVEY COMPLEI

144004

OA

C

NAME OF okoviosteesupisunt.

SPRINGFIELD HOSPITAL

srea.-r, Ws* dirt 'epee, ZWCODE - p0 BOX ZOPZ SPRINGFIELD, VT 051.56

000 ID PREFIX . T40

SOIVINIARYATAitAIERTAPP REFOANOIES L4PraIDXFICIEhleYW4StEfE PRECEDED BY FI.ALA.,

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to PREFIX

TAG

onomows PLAN OF CORRECTION ' APAT0AceRRecroitActtoN AHOUWAE CROSS-nErtgENCED TO THEAPPROPRIATE

DEFICIENCY)

Pis) COMPLErrent

WM

C2 Contlneed kern

#1 remained DoPPOlSve. NOtEr,211011 err deannients Patient

. helped". When consulted Manager Of a psychiatric had previous hospitalizadeas, Center Nurse Manager documented that twispitattzatio os .....,They have never seen hisiter taritiri9 and teatil sine: le, s/he-has staff niefiltietit 12111/13 progresS cc:repel-etre 01)6.W kority Opal Wee:as:signed

Per tatient-PriagreSS 167:6G, Ratienttf 4`,.,00Viriti a diffieUlt

1114 Merit :VMS IViiireeted his/her morn.. Shortly to betranSiated, renSning 0 control this 101e,110:10 provided,- attempts tingeing flail was secticitystaff was seskIsionteldet room decision wasinade transfer the patientto (ED) at Springfield could provide requested and accompanied Officer and without palatinel dignity waSMITioVed tern

pa Itin Okr..thenlecilcatlen

*01.19 •Selniatingligtitaii,4s0outt

pager

Sitilfai the: NWS.Q # I *ate-. fl "i- 419; , ,

and , , on 12/1111Srthe

unit where ., the

wasinforined during Pailentitill

(other psychiatric him/her touthanyone,

raving. and telling never adtialtylotiehed

Wrenn During the notes indiCate Patient#1 additiorial monitoring

tithe patient

Note for 12/12/13 *00Safid tO. staff i - tine and n—leported

antegfaea after, Patient#1

Wftbitig OPPOerna POPPt of his/her bohavimz

rianel ttleraPeAtiezel4PpOrt to stOilirg were not offered' additional

not scheduled, use was not utilized,

by Windham Center the Einergency

Hospital so County Local police.

by a State consideration Of Patieritfits

and Patient Rightt, the WindhaiP Center

PrnPationt-frogrOas

Staff

%Ile' claPsorbOs

ma* . Nurse . _

Patient ti pd am and.

previous unify

despite people how

a nightef ,

was a

at sibewas - .. haV411)

inienbet, to ataSS in

retiOetted

DkirfrIg Was

not evident;

pfitho and the

staff to Department Sheriffs

were Police

Patient #1 and

S 253.

rt

Windham Center patient transfers to the Emergency Department The policy for "Medical and Acute Medical Emergencies- will be reviewed and revised. The policy will then be reviewed with all Windham center staff to provide guidelines for transfer of Windham Center patients to the Emergency Department. Monitoring The Nurse Manager and Medical Director of the Windham Center will review all cases of patients transferred to the Emergency Department using the guidelines from the policy and document their findings. Feedback will be given to staff based on those findings. Follow up Failure to adhere to policy will result in immediate re-education of staff and case review.

Police involvement with patients of the Windham Center A policy will be developed to identify appropriate police involvement for patients of the Windham Center. Staff will receive education to this policy. Monitoring The Nurse Manager and the Medical Director of the Windham Center will review any incidence of police presence at the Windham Center. Events impacting patient rights and dignity will be reported and that a review these events will occur. Follow up Failure to comply with the policy will result in case review and re-education with staff.

11- IC - )41

41. 4'1 Y

FORM0.062667(02-99) ous Versions Obtolete Event1a29TR11. Facility 10:2171a06 if continuation sheetPage 80)15

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From:NetJets Bradley Office 802 885 7389

DEPATTMENTOFFEW:nifOlDf8-1MANSEIRVRES '

04/02/2014 06:48 11431 P. 011/017 PRIMMX OM-42014

FORM APPROVED .

STATBMENT OF OMO1010)09 AND PUN 09BORREOtION

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DEFICIENCY)

COMPLETION, DATE TAB

0263 ocatiatasa Rom rragaz _ _ although not chat ag handcuffed 9014 brought Online 8tatiOn at 16 patient of the thedieei oversight by Patient #1 9,WI.P.4etalf* atthepolice-Statiorf while still being considered Wironamteptari Patient4l tote.:Springfletd. Hospital 12112/13,

Patient#1 remained continued te be -considered Windham Center, without therapeutic Millen of detained, Patient #1 small exam: tocsin in Cate 1J dit Monitored Sectrityand a Mental until 12,2Dit3, .Padent_fit1 anotherrsycHhiatrio

par Windham' center APPlesitti 6/13113 atatee Septledillinsterl Tvianttfomr PIVA*444:00100400154-aaaeSMOritt

rapid retUrn to comp:wit/ Wowevpr; per-interviewer) Ilmr4a ISt4ng:cratateti Ole to manage pm compliantpetients who they do accept 72 hour Wheals° stated staff fa-the administration psythetroOic erneivency patient is refusing to the Windham Center:

Withe Criminal OffenAAi WAS to the WO* Fab

45: Whiki Stijl beriaiderel a Center but VilthOet any

kffifindharn center SO* for greatritien 2 Nuts

ROM the pollee *SOT, - a patient at te .wastep -transferred

Ea and at2124 On

in -tfie ED for 8 days* a patient of the

the bertefft of a a psychiattictadity. While, wasesSigned to either a

D 268

t,

,

-OjgtaFetabi1igetiOn,,rnedioa5on:manageiMnt,,end

the Ea or theArnbtilatory by County Shenfisthdlar Ilealth.Worker, It was not

Was tratinfemed to Unit

inpatient Kan Ofteretast 11 The Windham Center

bows a aayaria rapid

ItigtiC 20/1/1 at 21$ PM, the

tho'vywharn .boniot Is aggmssiyo and medication

are not violent, however involuntary admissions

transfers patients to the ED of a intramuscular

medication When a take. the Medication orafiy at

The Nurse Manager

FORM cmo-.7.55/052499y Previcios Versiooe Obsolete Event lOaSTRII Fpciiiy to 01499

licabrewallarl ebee Page 9 of ft

802 885 7389 04/02/2014 06:49

CENT

From:NetJets Bradley Office

DEPARTMENT OF HEALTH AND HUMAN SERVICES:

11431 P.012/017

PRINTED: 02414/2014 FGRIVIAPPROVED

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_IN l (0 mem* SUMMARY STATEMENT OP DEFICIENCIES

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WEPIX 'PROVO_ PLAN OF , ..Eft8

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i

0253 Cortnuerl FY= page 9 C253. justified transfers to the Springfield Hospital ED

tinoltiding RisIrs and stating festal* initabets Mental Health 1Neitera) fitidifficieht to safely adninistot emergency medications, noting It was herNe OPiriba the procedure Watild regalia 5 Siff Ind*** te,OSSittWith PhYdnallyhOldihg a pttient tfiartnistot the 0019001toctoitgt Per revieWof staffing Schedules toted mete- Was motet* 04 deft Schednie4.00 -an Shift With days having the OtI4RIOPC1100-ROTIt atheNurs0 WIRget,

. . in,addition, •iip. fitrIberdisenesientegarOing staffing-and trait Safe* the Mae Mehger ilia conhrai the Winatrani Center Would follow the Serin2tield Hospital PerlcY titie4 Won<Plaee Violence laatreviewed 5/10/1:20t* poll*dresses:NW employees grate respond it there Was a ihse of violence involving a Patient do* currentor termer employee or a stranger within the workplace. For the Windham Center, Staff are to notify the switchboard to announce a ',bode Orange,. During the dey, designated outpatiehttlepartmentemployees located within ;the same fitlildingeasthe Windhain Centerirould ariNe on the unit to wovideaSkow of support Howthrer4 Nhthen the oUtpafiehtefficeS are dosed, callirig a Code Orange' would not staff. On the atenting Of 2/4/121-the Nurse Manager stated that :dudes off hours giVen the Dreamt Staff Serrefile, tan emergency sitliatien did altra Staff are to can 911, however einolits. station la 15 Minutes away, hospital staff are located aPProkirrlistelY $ minutes away noting N..Sie are bastally our own". Furthermore opting 90% 0t.thaff are female at the Windham eonter,

0 306 485.638(aXiii) 'RECORDS SYSTEMS C 306,

FORM CMS-037(0249) Previous Versions Obsolete

Event 7911111

Paciljty 4).i-471190

Itcootinuatlart sheet Page 1-0 of 15

04/02/2014 06:50 802 885 7389

CEN E R

From:NetJets Bradley Office

DEPARTMENT OF HEALTH AND Ift.IMAN S/ICES

#431 P.013/017

PRINTECk 02/14/2014 FORM APPROVED

el04'ro crc Me ritompeoanaonot4 d J ikA Ice(orlokTfee *wen:

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This STANDARD eiBectoll radon]

nursing etattfalled pertinent informatien monitoring Of

Daidarttnent

. Per record the*Yaliiatrie 214$ (9:45 PM), avbiad aft* and Wired accepted of *hilt ptent0 rookie:AN *flattery disorganized

SOO laystalf Otherpaherits. written Priortote Springfield Hospital for evaluation Nurse (RN)

reqtiifiecftifthettraatfnent

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trot lore

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petinix6

is

'to

(Veteran)

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for medical

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was -written at 10:00.

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reviewilNindharn

a patient*ho

EON/tete-Patient:it

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10

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of mediellie or osteopathy or Warta or travoispm)

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itIO *OS MVOS, such aril plThress notes

response to treatments;

not Metas-evidenced:by: Center

oompletetyidoeurnent necessary during the

Wasidentified to in the Erneigenby EMS/ inelOde:

2 Wet :attinitted404. 214120:10tapprOXiinately

was fireteeari and HttOlinedl‘ Hospital

OWPOges 010'10 Wog Center 'Ogre the

$ychotic features- Sae! tialledh.aaaha and needing to be

intrusive behaviortoward nurse pmgres0 note

being transferred to The Emergeney Department (EIS)

174 /fr/ Documentation: Staffwill be re-educated to accurately document

assessments to identify at risk behaviors that accurately indicate a requirement for increased staffing; implementation of therapeutic alternatives; consideration of seclusion or restraint to ensure patient safety. A Behavior Flow Sheet will be developed that idenes and provides documentation for: at risk behaviors; interventions implemented; outcome of treatment. Monitoring: Behavior flow sheets will be reviewed to assess completion of appropriate assessments; Implementation of appropriate interventions; and treatment outcomes. Goal: All patients are treated with dignity and respect. Follow up Any failure to comply will result in review of situation and re-education with staff and identification of further improvement efforts.

by the Registered PM. The note detaila The

FORM et4S-2§0(62491Breitibus Veisions °Fascia, EuenitDiZGTifY nianyinsiiase If to nustion liee:t Page 11 Of 15

From:MetJets Bradley Office

802 885 7389

04/02/2014 06:50

#431 P.014/017

„ . RKINITED; U2 /1q20141. tOkAttaMtisit OF HEALTH AND tiftrAN SERVIGES PORMAPPROVE0 CENTERS FOR MEDICARE Si MEDICMD.SERVICES OMIE314a. tt93: 4391.

STATEMENT or-opposites AbltPLANOF CORRECTION

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PROVIDER'S PLAN or CORRECTION (EACH coanncrivsAcrioNseioULOSS

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DATA

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. continued From page 11

P , .4ttent as heft i$Sorgentied, agitated, and tearf ul and admitting to hearing voice% The rairsetUritier Stateelhat the patient initially spit out PerbetioPlo MedioaSiOri to help-sedate ittimiheri and was placed on IS minute Observations for,satety. The-documentatten theAS minuteicibservation form details the patient frorrtle6 PM until tratristerkrthe ED- as:fellows: 't.withitaft WhfSPering, resting, lying oft floor, agitated andorying„...../. There is no downier:Won in the nurses note regarding patent being intent, threatening, or Lininanageabie, Theta rid docaUrrerytation Medina( retOrd Matte patient reqUirad any emergency Interventions 'OriOt to hisibertrafer to the Springfield Hospital ED, There is a teettot (10aliterititiOn in the friddinal nliinitl inc:intlude• bOth PhYliciart notes and nursing notes that Patie,mt #2 (requited) a second emalUatiOn fdr possible niedidal rea$One not cli$0,1* in Dniintnikb. finobot(a Rbspitotiovitaloo, 485.€4104(6)(ii):QUALITYASSURANCE

[Theoremart requires ti at—] the 0Atfalse takes appogriate rernedial StOtieti atldnaSS detidenoleS fOuritt through the ginali4f atatitailtiRtittigatt,

This STANPARP Ft nett)* as yi0erisepf flossil PP record review anti QOPfirrned through stifiriterviews,the WRY failed to lecOgrliae eitettYngYfor improvement and laed to address previously identified iSsuesiconcerns documented as adverse. events. Findings include;.

t Per record review Patent # 2 was admitted

on

the

In the

the

lb

W

to

C 3D6'

0 342, Event Reporting and Review Failures to comply with situations that impact patients' Bill of Rights, dignity and respect will be reported and reviewed to assess compliance with policy and regulatory requirements. Improvement activities will be identified to support the respect and dignity of patients.

Monitoring Review of medical records to determine events impacting patient rights and dignity are reported and that review of events occur and result in further education and identification of improvement activities that result in respect for patients' rights and dignity. Monitoring

y-it,-)'f

FORM CMS 2667(0799) Previous Versions 0

Event ID:29TR11 Fad 511D:471305

if confirmailOn ghteiritqe 12 of 15

From:NetJets Bradley Office

802 885 7389

04/02/2014 06:51 #431 P.015/017

DEPARTMENT or HEALTH AND 1118041 SERA IPEE TE F

PRINTED; ‘02h4/2b14 FORM APPRovO?

G*TEMENTOFOEFICIENUIES 4o PLAN 0 CONRECTIOhl

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SUMMARY STATEMENT OF DEFICIENCIES (EACI DEFICIENCYMUSTSESRECEDED BYRAS

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C 343 Contiotterl POMPaga 11 the' iipsychiatricTh.rotton 2/25/2O13-sitapproxiinateiy 045.(9A5 PisiThThiapatient evaluated at the Dartmouth and cleared for meintal purposes accepted at theWindhatatenterwheM patientpretehtediWith paybitotta including r a uditOty , a rid Vista diSorgaiitzeinetintior, and redirected by Staff fortnttittiVa .other tuitianta, The patieitaaastieteriba4 nursing PC40 as ditig agitated, dtIttilitinak heating voices. Was aditinietemad oral psyehotropic smelpitiany spit (foot. boomitontation Minute Obeiatketitiin fetttlettiOteil$ "–with WA wiaspetirV, Testing, agitated and crying,..... , Nurse's Identify thepatteht as being or timnanageable. Within 2 nursing staff trade teitlettseninaliOn required ott4PottuatiO4 and OCIreinietefiellIcy injection of esysttutropie medication and )0004111g PaYentatriat to ogler pabentto the Etiat $prirtgiftald staff coUldassessthe patient

Perinterview on 2/4114 at 1.0;15,AM, Director for the Windham Centetstated hasthe medication and ability 'ntramuscuI•at'einergattCy inVoliintary however &sing a 'previbtlainterVieW 225 PM the Nurse Manager lack of sufficient steno handle of an ethergeney involuntary SafetyEvent had been completed Patteht#Zattensfer to the staff regarding the eitommetanbet to re-Oat:nine Patient #2 had

was first seen ihikticookhiospitar

Oar to

features tralludhatibm

rbeedingle be behaViortuwartl

and Nett When the Patiett

Illedtatien On the

Patient tying on hole old

violent, threatening;. fou!s of atinllSalett,

West* en Meta:encl. requested the etTenefer of Hospital where

and-medicate

the toadrilinistei-

on 2/3'/14 stated there

theadriiiiiistretiOn injection. A Patient

at the tune ED. Response

and necessity been in miestioni

the

the Patient

the.Medibat

itedicatiOn,

and

being

In a and

15 *2.05:: floor, not

the

unit

-at was

of by ED

G Follow up Any failure to comply will result in review of

ti situation and re-education with staff and identification of further improvement efforts.

FORM CMS-2597(02-00) Previous' bng Obsolete Event 11129TR1 FathitY Pr 4743C* If tOntintiatiOn sheet Pogo 13 of 13

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04/02/2014 06:52 802 885 7388

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1.4MR-ekeNT OF HEALTH AND 1-11.34,449 SERVICES

11431 P.016/017 PRINTED: 02/1472014

k]PRIVI APPROVED

STJlTEp1ENTOF DEFICIENCIES AND P OPOORRECTION

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